Supportive psychotherapy began as a second-class treatment whose only operating principle was “being friendly” with the patient (Box).1 Critics called it “simple-minded”2 and sniffed, “if it is supportive, it is not therapy…if it is therapy, it is not supportive.”3
Since its lowly beginning, however, supportive psychotherapy has been proven highly effective, and clinicians have developed operating principles that distinguish it from expressive psychotherapy (Table 1).4
To help you make good use of supportive psychotherapy, this article describes its evolution and:
- evidence that demonstrates its effectiveness
- 5 key components for clinical practice
- how to use it when treating challenging patients.
Table 1
Differences between expressive and supportive psychotherapy
| Component | Expressive psychotherapy | Supportive psychotherapy |
|---|---|---|
| Treatment goal | Insight | Reduce Symptoms |
| Therapist style | Opaque | Conversational (“real”) |
| Transference | Examine | Nurture positive transference |
| Regression | Enhance | Minimize |
| Unconscious | Explore | Focus on conscious material |
| Defenses | Interpret | Reinforce mature defenses |
| Source: Reference 4 | ||
A proven treatment
Effective long-term therapy. Much research on supportive psychotherapy comes from studies in which supportive psychotherapy was included as a “treatment as usual” comparison. In an extensive longitudinal study, for example, the Meninger Psychotherapy Research Project examined 42 patients receiving psychoanalysis, psychodynamic psychotherapy, or supportive psychotherapy over 25 years.5
Despite the institutional expertise in psychoanalysis and expressive psychotherapy, patients in supportive psychotherapy did just as well as those receiving the other treatments. Researchers found that each therapy carried more supportive elements than was intended, and supportive elements accounted for many of the observed changes. They concluded that:
- thinking of change in terms of “structural” vs “behavioral” was not useful
- change did not occur in proportion to resolving unconscious conflict.
A supportive approach may work when expressive psychotherapy fails
Combating phobias. A study of behavior therapy for treating phobias had similar results.6 Patients with agoraphobia, mixed phobia, or simple phobias were treated with behavior therapy alone, behavior therapy plus imipramine, or supportive psychotherapy plus imipramine for 26 weekly sessions.Early psychotherapy consisted of directive methods by which Charcot, Freud, and others “suggested” that patients rid themselves of symptoms while under hypnotic trance. Beneficial effects were sometimes immediate and dramatic but rarely lasted.
Dissatisfied with directive techniques, clinicians developed psychoanalytic principles and expressive psychotherapy, which emphasizes analyzing transference and uncovering unconscious thoughts, feelings, and motivations. Although expressive psychotherapy became popular, many patients—especially those with severe mental illness—were deemed unsuitable candidates or failed to improve.
These patients were relegated to supportive interventions, which initially were vaguely defined methods to reduce anxiety and provide encouragement. Therapists required little or no specialized training to provide supportive therapy and did not expect patients to make character (or structural) change. Surprisingly, many patients improved despite vague therapeutic guidelines.
Source: Reference 1
Therapists in the behavior therapy group used a manualized, highly structured treatment protocol that included in vivo desensitization and homework. Therapists who used supportive psychotherapy simply encouraged patients to ventilate their feelings and discuss problems. Supportive therapists were instructed to be nondirective and avoid confrontation unless the patient proposed it.
Improving personality disorders. Several studies examined a form of supportive psychotherapy that used a manualized, structured protocol for treating higher functioning patients who traditionally have been treated with expressive psychotherapy. The protocol used a conversation-based, dyadic style to improve self-esteem and adaptive skills through data-based praise, advice, education, appropriate reassurance, anticipatory guidance, clarification, and confrontation. Under these reproducible conditions, supportive psychotherapy showed good efficacy compared with dynamic therapies for patients with depressive, anxiety, and personality disorders.
A review of studies from 1986 to 1992 found that supportive psychotherapy was effective for a variety of psychiatric and medical conditions, including schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, anxiety disorders, personality disorders, substance abuse, and stress associated with breast cancer and back pain.9
CASE STUDY: A negative experience
Mrs. S, a 32-year-old grant writer, is referred to a psychiatrist by an emergency department physician after she cut herself following an argument with her husband. She has chronic dysthymia, thoughts of harming herself, low self-esteem, and indecision about her marriage.
Mrs. S was not receiving mental health treatment because her first experience with a psychiatrist had a poor outcome: “He hardly ever said anything; in fact, sometimes I wondered if he was sleeping. I needed advice desperately, and I was hoping to get some help and direction for my life. Instead he answered every question with a question, and I ended up getting more confused. I felt guilty, like I wasn’t being a good patient because I couldn’t think for myself. I felt like he thought I was stupid. He gave me some antidepressants, but after a few months of feeling even worse I stopped going and vowed to never see a therapist again.”